The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?
Ankle ulcer that is healing slowly.
History of alcohol abuse and cigarete smoking.
Recent weight gain of twenty pounds.
Newly prescribed antihypertensive medication.
The Correct Answer is D
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.
A. Explaining the examination and asking the client to sign the consent form is not the responsibility of the PN but of the provider who will perform the examination.
B. Obtaining the medical record for the correct signed consent form prior to the examination is not enough to ensure informed consent and may not involve any interaction with the client.
C. Asking if the client understands the exam and why the consent form must be signed is not enough to ensure informed consent and may not address any questions or concerns that the client may have.
Correct Answer is A
Explanation
The correct answer is choice A: Never scratch under the cast.
Choice A rationale:
It is important not to scratch under the cast because inserting objects can lead to skin injury and infection. If itching occurs, blowing cool air from a hair dryer into the cast is recommended.
Choice B rationale:
While mild swelling and some discomfort are common after a cast is applied, patients should not expect an increase in pain. Persistent or severe pain could indicate complications such as increased swelling, decreased blood flow, or pressure on nerves and should be evaluated by a healthcare provider.
Choice C rationale:
Applying a cold pack to “hot spots” on the cast is not recommended as it can lead to moisture accumulation and skin problems. Instead, to manage swelling and discomfort, ice can be applied over the cast, covered with a thin towel, for 20 minutes every two hours while awake during the first 48 hours.
Choice D rationale:
Keeping the injured leg in a dependent position is not advised because it can increase swelling and pain. The affected limb should be elevated above the level of the heart to reduce swelling and promote healing.
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